World report on violence and health A B S T R A C T World Health Organization Geneva
This report makes a major contribution to our understanding of violence and its impact on societies. It illuminates the different faces of violence, from the invisible suffering of society s most vulnerable individuals to the all-toovisible tragedy of societies in conflict. It advances our analysis of the factors that lead to violence, and the possible responses of different sectors of society. And in doing so, it reminds us that safety and security don t just happen: they are the result of collective consensus and public investment. From the Foreword by Nelson Mandela Each year, over 1.6 million people worldwide lose their lives to violence. Violence is among the leading causes of death for people aged 15 44 years worldwide, accounting for 14% of deaths among males and 7% of deaths among females. For every person who dies as a result of violence, many more are injured and suffer from a range of physical, sexual, reproductive and mental health problems. Moreover, violence places a massive burden on national economies, costing countries billions of US dollars each year in health care, law enforcement and lost productivity. The World report on violence and health is the first comprehensive review of the problem of violence on a global scale what it is, whom it affects and what can be done about it. Three years in the making, the report benefited from the participation of over 160 experts from around the world, receiving both peer-review from scientists and contributions and comments from representatives of all the world s regions. 2
WHY THIS REPORT? There is a common perception that violence is an inevitable part of the human condition, that action to prevent it is the responsibility of the criminal justice system, and that the principal role of the health sector is the care and rehabilitation of victims. These assumptions, however, are being challenged as progress in preventing a range of other environmental and behaviour-related health problems such as heart disease, smoking and HIV/AIDS has demonstrated the potential of public health to address the root causes of complex conditions. The World report on violence and health is intended to raise awareness of this potential and to call for a much wider and more comprehensive role for public health in the response to violence. Such a response involves the four classic steps of public health, namely: defining and monitoring the extent of the problem; identifying the causes of the problem; formulating and testing ways of dealing with the problem; applying widely the measures that are found to work. The report states that a public health response to violence prevention should be based on sound research and informed by the best evidence. A key requirement is that it be collaborative in nature, involving a wide range of professional expertise from medicine, epidemiology and psychology, to sociology, criminology, education and economics. The public health approach does not replace criminal justice and human rights responses to violence; rather, it complements their activities and offers them additional tools and sources of collaboration. DEFINING VIOLENCE One reason why violence has largely been ignored as a public health issue is the lack of a clear definition of the problem. The wide variety of moral codes throughout the world makes the topic of violence difficult to address in a global forum. This is complicated by the fact that notions of what is acceptable behaviour, and what constitutes harm, are culturally influenced and constantly under review as values and social norms evolve. Thus there are many ways of defining violence, depending on who is defining it and for what purpose. WHO defines violence as: The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation. The definition encompasses interpersonal violence as well as suicidal behaviour and armed conflict. It also covers a wide range of acts, going beyond physical acts to include threats and intimidation. Besides death and injury, the definition also includes the myriad and often less obvious consequences of violent behaviour such as psychological harm, deprivation and maldevelopment that compromise the well-being of individuals, families and communities. 3
THE ROOTS OF VIOLENCE No single factor explains why one person and not another behaves in a violent manner. In its analysis, the World report on violence and health uses an ecological model which takes into account the multitude of biological, social, cultural, economic and political factors that influence violence. The model has four levels individual, relationship, community and societal. At the individual level, the model examines the biological and personal history factors that increase the likelihood of an individual becoming a victim or perpetrator of violence. Examples of factors that can be measured include demographic characteristics (age, education, income), psychological or personality disorders, substance abuse, and a history of behaving aggressively or experiencing abuse. At the relationship level, the model explores how relationships with families, friends, intimate partners and peers influence violent behaviour by taking into account such factors as harsh physical punishment of children, lack of affection and bonding, family dysfunction, associating with delinquent peers, and marital or parental conflict. The third level explores the community context in which social relationships occur, such as schools, workplaces and neighbourhoods, and seeks to identify the characteristics of these settings that increase the risk for violence for example, poverty, high population density, high levels of residential mobility, low social capital, or the existence of a local drug trade. The fourth level looks at the broad societal factors such as social norms that create a climate in which violence is encouraged or inhibited. It also takes into account the health, economic, educational and social policies that maintain economic or social inequalities between groups in society. Besides clarifying the causes of violence and their complex interactions, the model suggests what needs to be done at various levels of government and society to prevent violence. THE FORMS AND CONTEXTS OF VIOLENCE The report uses a typology of violence that divides violent behaviour into categories according to who has committed the act, who the victims are, and to what kind of violence they have been subjected. Interpersonal violence Interpersonal violence violence inflicted by an individual or a small group of individuals includes youth violence, violence between intimate partners, other forms of family violence such as abuse of children and the elderly, rape and sexual assault by strangers, and violence in institutional settings such as schools, workplaces, nursing homes and prisons. Interpersonal violence covers a wide range of acts and behaviours from physical, sexual and psychological violence to deprivation and neglect. In 2000, an estimated 520 000 people were killed as a result of interpersonal violence worldwide a rate of 8.8 per 100 000 population. Many more suffered non-fatal and very often repeated acts of physical or sexual aggression. 4
While violence in the community, particularly youth violence, is highly visible and generally labelled as criminal, violence within the family (including child and elder abuse and violence between intimate partners) is more hidden from public view. Moreover, the police and courts in many places are less willing or prepared to target such hidden violence or to recognize and take action against sexual violence. The different forms of interpersonal violence share many common underlying risk factors. Some are psychological and behavioural characteristics such as poor behavioural control, low self-esteem, and personality and conduct disorders. Others are tied to experiences, such as lack of emotional bonding and support, early exposure to violence in the home (whether experiencing or witnessing family violence), and family or personal histories marked by divorce or separation. Abuse of drugs and alcohol is frequently associated with interpersonal violence, and poverty as well as income disparities and gender inequality stand out as important community and societal factors. Suicide and self-harm Globally, an estimated 815 000 people killed themselves in 2000, making suicide the thirteenth leading cause of death. The highest rates of suicide are found in Eastern European countries. The lowest rates are found mainly in Latin America and in a few countries in Asia. In general, suicide rates increase with age, with rates among people aged 75 years and older approximately three times the rates among people aged 15 24 years. Nonetheless, among those aged 15 44 years, selfinflicted injuries are the fourth leading cause of death and the sixth leading cause of ill-health and disability. In much of the world, suicide is stigmatized condemned for religious or cultural reasons and in some countries suicidal behaviour is a criminal offence punishable by law. Suicide is therefore a secretive act surrounded by taboo, and may be unrecognized, misclassified or deliberately hidden in official records of death. A variety of stressful events or circumstances can put people at increased risk of harming themselves. Such factors include poverty, loss of loved ones, arguments with family or friends, a breakdown in relationships, and legal or work-related problems. While such events are common experiences, only a minority of people are driven to suicide. To act as precipitating factors or triggers to suicide, they must happen to someone who is predisposed or otherwise vulnerable to self-harm. Predisposing risk factors include alcohol and drug abuse, a history of physical or sexual abuse in childhood, and social isolation. Psychiatric problems, such as depression and other mood disorders, schizophrenia and a general sense of hopelessness also play a role. Other significant factors include: physical illnesses, particularly those that are painful or disabling; having access to the means to kill oneself (most typically guns, medicines and agricultural poisons); having made a previous suicide attempt, particularly in the first 6 months after the first attempt. 5
Rates of suicide have also been linked to economic recessions and periods of high unemployment, social disintegration, political instability and social collapse. Collective violence Collective violence is the instrumental use of violence by people who identify themselves as members of a group against another group or set of individuals, in order to achieve political, economic or social objectives. It takes a variety of forms: armed conflicts within or between states; state-perpetrated violence such as genocide, repression and other abuses of human rights; terrorism; and organized violent crime. During the 20th century, one of the most violent periods in human history, an estimated 191 million people lost their lives directly or indirectly as a result of armed conflict, and well over half of them were civilians. In 2000, about 310 000 people died as a direct result of conflict-related injuries the majority of them in the poorer parts of the world. Besides the many thousands killed each year in violent conflicts, there are huge numbers who are injured as a result, including some who are permanently disabled or mutilated. Others are raped or tortured violent acts that are often used as weapons of war to demoralize communities and destroy their social structures. Similar to other types of violence, a range of health problems, including depression and anxiety, suicidal behaviour, alcohol abuse and post-traumatic stress disorder have been linked to conflict. Violent conflicts also destroy infrastructures, disrupt vital services such as medical care, and severely affect trade, as well as food production and distribution. Infants and refugees are among the groups most vulnerable to disease and death in times of conflict. Increases in morbidity and mortality rates among these two groups can be dramatic. Factors that put states at risk for violent conflict include: a lack of democratic processes and unequal access to power; social inequality marked by grossly unequal distribution of, and access to, resources; control of valuable natural resources by a single group; rapid demographic change that outstrips the capacity of the state to provide essential services and job opportunities. Certain aspects of globalization also appear to contribute to conflict. None of these factors may be sufficient alone to cause conflicts, but in combination they may create the conditions in which violence will erupt. 6
WHAT CAN BE DONE TO PREVENT VIOLENCE? As violence is a multifaceted problem, there is no simple or single solution. Rather, as emphasized by the report s ecological model, violence must be addressed on multiple levels and in multiple sectors of society simultaneously. This includes, for example: Addressing individual risk factors and taking steps to encourage healthy attitudes and behaviour in children and young people as they grow up, and changing attitudes and behaviour in individuals who have already become violent or are at risk of harming themselves. Influencing close personal relationships and working to create healthy family environments as well as providing professional help and support for dysfunctional families. Monitoring public places such as schools, workplaces and neighbourhoods, and taking steps to address problems that might lead to violence, as well as steps to raise public awareness about violence, stimulate community action, and provide for the care and support of victims. Addressing gender inequality, and adverse cultural attitudes and practices. Addressing the larger cultural, social and economic factors that contribute to violence and taking steps to change them, including measures to close the gap between the rich and poor and to ensure equitable access to goods, services and opportunities. The report gives an account of the various preventive responses that have been tried at these levels and summarizes what is known about their effectiveness. The report shows that interventions delivered in childhood, such as home visitation, have proved effective in reducing child abuse and also are among the most promising interventions for producing long-term reductions in violence among young people. Training in parenting and family therapy programmes are also approaches with positive, long-term effects in reducing violent and delinquent behaviour, and at lower costs over the long run than other treatment programmes. Programmes that emphasize relationship skills and social competency are also promising approaches to addressing interpersonal violence, while treatment for mental disorders and behavioural therapy programmes offer hope for reducing suicidal behaviour. Other measures, such as those addressing access to means, have proved successful in reducing homicide and suicide rates in some settings. The report also shows, however, that few programmes have been rigorously evaluated. There is also an imbalance in the focus of programmes community and societal strategies are underemphasized compared with programmes addressing individual and relationship factors. 7
LESSONS OF EXPERIENCE Despite major gaps in knowledge and a pressing need for more research, experience provides some important lessons about preventing violence and mitigating its consequences. Violence is often predictable and preventable Certain factors appear to be strongly predictive of violence, even if direct causality is sometimes difficult to establish. Identifying and measuring these factors can provide timely warning to decision-makers that action is required. Moreover, the array of tools with which to take action is growing as public health-oriented research advances. Upstream investment brings downstream results There is a tendency worldwide for authorities to act only after violence has occurred. But investing in prevention especially primary prevention activities that operate upstream of problems may be more cost-effective and have large and longlasting benefits. Resources should be focused on the most vulnerable groups While all social classes experience violence, research shows that people with the lowest socioeconomic status are at greatest risk. The neglect of their needs in most societies the poor are generally those least served by the state s various protection and care services has to be challenged if violence is to be prevented. Political commitment to tackling violence is vital to the public health effort While much can be achieved by grassroots organizations, individuals and institutions, the success of public health efforts ultimately depends on political commitment. This is as vital at the national level where policy, legislative and overall funding decisions are made as it is at the provincial, district and municipal levels, where responsibility for day-to-day administration of policies and programmes rests. 8
RECOMMENDATIONS FOR ACTION The multifaceted nature of violence requires the engagement of governments and stakeholders at all levels of decisionmaking local, national and international. The following recommendations reflect this need for multisectoral and collaborative approaches. Recommendation 1 Create, implement and monitor a national action plan for violence prevention National planning to prevent violence should be based on a consensus developed by a wide range of governmental and nongovernmental actors. It should include a timetable and evaluation mechanism, and enable collaboration between sectors that might contribute to preventing violence, such as the criminal justice, education, labour, health and social welfare sectors. Recommendation 2 Enhance capacity for collecting data on violence Reliable data on violence are crucial not only for setting priorities, guiding programme design and monitoring progress, but also for advocacy purposes. Without such information, there is little pressure on anyone to acknowledge or respond to the problem. Not only should data be collected at all levels, but it is equally important that internationally accepted standards for data collection be adopted to enhance the comparability of data across nations and cultures. Recommendation 3 Define priorities for, and support research on, the causes, consequences, costs and prevention of violence At the national level, research can be advanced by government policy, by direct involvement of government institutions, and by funding to academic institutions and independent researchers. Among many research priorities, there is a pressing need to develop or adapt, test and evaluate many more prevention programmes in both developing and developed countries. At the global level, issues calling for cross-national research include: the relationship between violence and various aspects of globalization; risk and protective factors common to different cultures and societies; and promising prevention approaches applicable in a variety of contexts. Recommendation 4 Promote primary prevention responses The importance of primary prevention and the lack of such programming in many countries is a theme echoed throughout the World report on violence and health. Some of the important primary prevention interventions for reducing violence include: prenatal and perinatal health care for mothers, as well as preschool enrichment and social development programmes for children and adolescents; training for good parenting practices and improved family functioning; improvements to urban infrastructure, both physical and socioeconomic; measures to reduce firearm injuries and improve firearm-related safety; media campaigns to change attitudes, behaviour and social norms. 9
The first two interventions are important for reducing child abuse and neglect as well as violence perpetrated during adolescence and adulthood. The latter three can have significant impacts on several types of violence. Depending on conditions in specific locations, most of these interventions can also have important mutual reinforcing effects. Recommendation 5 Strengthen responses for victims of violence National health systems as a whole should aim to provide high-quality care to victims of all types of violence, as well as the rehabilitation and support services needed to prevent further complications. Priorities include: improvements to emergency response systems and the ability of the health care sector to treat and rehabilitate victims; recognition of signs of violent incidents or ongoing violent situations, and referral of victims to appropriate agencies for follow-up and support; ensuring that health, judicial, policing and social services avoid a renewed victimization of earlier victims, and that these services effectively deter perpetrators from reoffending; social support, prevention programmes, and other services to protect families at risk of violence and reduce stress on caregivers; incorporation of modules on violence prevention into the curricula for medical and nursing students. Each of these responses can help minimize the impact of violence on individuals and families and the cost to health and social systems. Recommendation 6 Integrate violence prevention into social and educational policies, and thereby promote gender and social equality Much of violence has links with gender and social inequalities that place large sections of the population at increased risk. In many parts of the world, social protection policies and programmes are under considerable strain. Many countries have seen real wages fall, basic infrastructure deteriorate, and steady reductions in the quality and quantity of health, education and social services. Since such conditions are linked with violence, governments should do their utmost to maintain social protection services, if necessary reordering the priorities in their national budgets. Recommendation 7 Increase collaboration and exchange of information on violence prevention Better working relations between international agencies, governments, researchers, networks and nongovernmental organizations engaged in violence prevention are needed to achieve better sharing of knowledge, agreement on prevention goals and coordination of action. The contributions of advocacy groups such as those concerned with violence against women, human rights abuses, abuse of the elderly and suicide should be recognized and encouraged through practical measures such as offering these groups official status at key international conferences and including them in official working groups. 10
Recommendation 8 Promote and monitor adherence to international treaties, laws and other mechanisms to protect human rights Over the past half-century, national governments have signed a variety of international legal agreements that have direct relevance to violence and its prevention. While many countries have made progress in harmonizing legislation with their international obligations and commitments, others have not. Where the obstacle is the scarcity of resources or information, the international community should do more to assist. Recommendation 9 CONCLUSION Violence is not an intractable social problem or an inevitable part of the human condition. We can do much to address and prevent it. The world has not yet fully measured the size of the task and does not yet have all the tools to carry it out. But the global knowledge base is growing and much useful experience has already been gained. The World report on violence and health attempts to contribute to that knowledge base. It is hoped that the report will inspire and facilitate increased cooperation, innovation and commitment to preventing violence around the world. Seek practical, internationally agreed responses to the global drugs trade and the global arms trade The global drugs trade and the global arms trade are integral to violence in both developing and industrialized countries. Even modest progress on either front will contribute to reducing the amount and degree of violence suffered by millions of people. World Health Organization 2002 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). Design: Tushita Graphic Vision, Tushita Bosonet, Geneva, Switzerland 11
Violence cuts short the lives of millions of people across the world each year, and damages the lives of millions more. It knows no boundaries of geography, race, age or income. It strikes at children, young people, women and the elderly. It finds its way into homes, schools and the workplace. Men and women everywhere have the right to live their lives and raise their children free from the fear of violence. We must help them enjoy that right by making it clearly understood that violence is preventable, and by working together to identify and address its underlying causes. Kofi Annan, Secretary-General, United Nations, Nobel Peace Laureate, 2001 Massacres, forced displacement of populations, discriminatory access to health care in the contexts in which MSF works, violence, particularly political violence, is often one of the main causes of mortality. The absence of this category in epidemiological registers often reflects the ambiguity of doctors and experts to authorities in power. This report is a welcome break in this wall of silence. Morten Rostrup, President, Médecins Sans Frontières (MSF) International Council, Nobel Peace Laureate, 1999 A stronger commitment to increase global violence prevention efforts is desperately needed. Therefore, I welcome this report very much. For the first time all of the available knowledge has been assembled into one publication. Civil society, United Nations agencies and governments need to work hand in hand on the implementation of the recommendations of this report. Jody Williams, International Campaign to Ban Landmines, Nobel Peace Laureate, 1997 As long as humanity continues to rely on violence to resolve conflicts, the world will enjoy neither peace nor security, and our health will continue to suffer. This report is an important resource for opening our eyes to the reality of violence as a public health problem, and for providing a source of hope for the future. Perhaps only when we realize that violence is destroying both our bodies and our souls will we begin to collectively address its roots and consequences. This report is an important step in that direction. Oscar Arias, Former President of Costa Rica, Nobel Peace Laureate, 1987 WHO has made a substantial contribution by providing a global perspective on all forms of violence. The colossal human and social cost of violence hitherto has been inadequately addressed as a public health issue. This report will raise the struggle against violence to a new level of engagement by health workers and others. Over 20 years we in IPPNW have maintained that nuclear weapons and war are the ultimate expressions of violence that must be eliminated if we are to bequeath a liveable planet to generations yet unborn. Anton Chazov and Bernard Lown, International Physicians for the Prevention of Nuclear War (IPPNW), Nobel Peace Laureates, 1985